Dip or chew, the brochure warns, and you, too, could lose chunks of your head to a surgeon's knife.
The cowboy, a.k.a. Don Morris, doctor of education, puts down the brochure and looks for another, sifting through the collection of antitobacco materials that takes up much of one room in his north Scottsdale home. Since 1990, the former professor has been employed as the executive director of Arizonans Concerned About Smoking, a nonprofit organization that sends Morris in a cowboy hat and a bola tie to Valley schools to spread his antismoking message.
Morris picks up a poster showing professional baseball player Bill Tuttle--on the left, he's in uniform, circa 1959, his cheek distended by a vast wad of chew. On the right, the same man's head has become a nightmare of swollen flesh, rows of stitches and medical tubing, the result of a 131U2-hour cancer operation which removed the largest malignant mouth tumor his doctors had ever seen.
"Gruesome, isn't it?" Morris says as he hands over the poster. He can't spare samples of everything he gives to students--he has to have enough for the kids themselves.
Like other antitobacco activists, Morris operates on a limited budget and with limited effect. The combined efforts of dozens of health agencies in the state, Morris says, can't begin to compete with a tobacco industry that yearly inundates the nation with billions of dollars in advertising.
In Arizona, however, all of that was supposed to change with the passage of Proposition 200 in 1994.
The ballot measure raised taxes on cigarettes to 40 cents a pack, and earmarked the additional tax revenue for indigent health care and what promised to be a state-of-the-art antitobacco media campaign. Millions of dollars would be collected from smokers to do on a statewide scale what Don Morris and his bola tie had been doing locally for years.
Morris himself was rewarded for his dedication by Mark Killian, speaker of Arizona's House of Representatives, who appointed the UnMarlboro Cowboy to the Tobacco Use Prevention Advisory Committee (TUPAC), which oversees Proposition 200 spending on health education.
But Morris and other members of the health-education community fear that Proposition 200 is in trouble. The measure's opponents, antismoking advocates say, haven't stopped fighting the initiative despite its passage by Arizona voters. Among other things, those advocates charge that some of TUPAC's members are legislators who were openly opposed to the tobacco-tax proposition, as well as private citizens with ties to the tobacco industry.
Those advocates also claim the tobacco industry has been behind efforts to discredit Jack Dillenberg, director of the Department of Health Services, in regard to contracts he negotiated with the Phoenix Suns and the Arizona Cardinals for an antismoking media campaign.
And, the advocates claim, political pressure has already compelled DHS to dilute its antitobacco message and shift its focus, perhaps lessening the potential effect.
It's a familiar list of charges, say health professionals who monitor the tobacco industry on a national basis. Tobacco-tax measures in California, Massachusetts and Michigan have produced a similar litany of political battles. Arizona's talent for internecine warfare, however, has activists taking note.
"I thought it was bad in California," says Dr. Stanton Glantz, professor of medicine at the University of California at San Francisco, "until I came to Arizona and saw what was going on here."
Almost immediately after Proposition 200 passed in 1994, lawmakers who had opposed it announced their intention to gut the program.
Not only had Arizona voters raised taxes on tobacco by bypassing the state Legislature, but those funds were earmarked for specific purposes. Voters had infringed on lawmakers' single greatest power: the ability to spend taxpayer money as they see fit. And there's nothing that seems to anger some members of Arizona's part-time Legislature more.
"I'd repeal it if I could, personally," Senate President John Greene said last January. "It's not slamming the public, that they don't know what's good for them, but how do you expect them to make a rational choice with all these commercials that they got barraged with?"
The day after his comments appeared in local newspapers, Greene was spotted at a Phoenix Suns game using the seats of a Philip Morris lobbyist.
Legislators introduced two bills that month which would have effectively killed the measure. One proposed to delay spending cigarette taxes until a study of unspecified duration was completed. A second bill, sponsored by Representative Jeff Groscost, Republican of Mesa, simply proposed to dump the revenue from the tax into the state's general fund.
"I don't know why legislators react this way to voter-approved initiatives," says state Representative Susan Gerard of Phoenix, who has frequently defended the proposition.
Proponents of the tobacco tax felt that Groscost's bill posed such a threat that they asked former senator Barry Goldwater to appear before the House Ways and Means Committee last January.
"When the people have voted in favor of something," Goldwater testified, "I don't think it's incumbent on the legislative body to try to change that."
The bill died in committee.
Many observers predict, however, that Groscost's bill won't be the last attempt for legislative control over the tobacco tax, which has turned out to be a revenue gold mine.
Estimates of what Arizona's smokers would raise for the health initiative had ranged from $36 million to $90 million. While the final figures for the first year aren't yet in, it's clear that well more than $100 million will have been collected. About $10 million has been allocated for spending on health-education funds in the first year, and $5.5 million of that has been earmarked for a media campaign.
To date, lawmakers have been unable to divert tobacco-tax funds from their intended use. They have, however, tried to make sure the nonprofit organizations primarily responsible for Proposition 200's passage wouldn't be seeing a dime, either.
Last April, the Legislature passed a bill to establish how tobacco-tax money would be spent. And one of its provisions limited the eligible recipients of local health-education contracts to political subdivisions (that is, schools and community health centers, among other entities), to the exclusion of nonprofit organizations.
Publicly, both lawmakers and nonprofit organizations say that the exclusion of such groups is a prudent measure to prevent misuse of taxpayer money. Privately, many sources say the legislation was a form of punishment for the groups who backed Proposition 200.
State Senator Jan Brewer, who opposed Proposition 200, disagrees. "I think it was done," she says, "because it was an initiative that was proposed to tax the people of Arizona for a self-serving purpose, to serve [the nonprofits'] pockets, personally."
In recent months, it's become clear that nonprofit organizations still will be able to receive tobacco-tax money as subcontractors. In other words, schools might pay the American Lung Association to provide materials for antismoking presentations.
"We know that some of the dollars are now probably going to ... some of those agencies on a subcontracting basis," Brewer acknowledges. But she's quick to add: "They will know that the service better be delivered and that it better not just go to padding salaries and office space and stuff."
And to make sure that doesn't happen, the Legislature also created the Tobacco Use Prevention Advisory Committee--which shortens to the unfortunate acronym TUPAC--to oversee the spending of health-education funds.
While TUPAC debates the access of nonprofit organizations to subcontracting funds at its December 11 meeting, Matthew Madonna sits in the audience doing a slow burn.
The director of the American Cancer Society's Arizona affiliate, Madonna was a key member of the coalition that backed Proposition 200.
Twenty-three cents of each tax dollar raised by the initiative go to health education for "programs to discourage tobacco use among the general population, as well as minors andculturally diverse populations." Another 70 cents go to a "medically needy account" for services provided by the state's indigent health-care system. The remaining 7 cents are split between health research and the Department of Corrections.
It is the education money that has drawn most attention so far. This money is administered by the state Department of Health Services, which is instructed to advise TUPAC of the programs it establishes and funds.
Some of the most outspoken opponents of Proposition 200, and others with tobacco-industry ties, sit on TUPAC. Maybe that's why Madonna looks like somebody's asked him for a smoke.
"There are five people who don't belong on that committee," he mutters. He doesn't elaborate.
The panel is chaired by Jack Dillenberg, director of DHS. Speaker Mark Killian appointed two members of the House: Gerard, a Republican, and Representative Andy Nichols, a Democrat. Senate President Greene appointed two senators: Republican Brewer and Democrat Gus Arzberger.
Also, six members of the public were chosen. Killian selected Don Morris, the UnMarlboro Cowboy, and Dr. David Nielsen, an ear surgeon well-known for his antismoking efforts.
Greene appointed Dr. Michael Hughes of the state Board ofEducation, and Maura McHugh, who represents the Business Council for Alcohol Education.
Governor J. Fife Symington III opposed Proposition 200, as did Greene, Brewer and Arzberger. The governor's appointments seem to reflect his sentiments on the tobacco-tax measure. They were Jack Braddock, who lobbies for Golden Eagle Distributors, Tucson's source of Budweiser, and Michelle Ahlmer of the Arizona Retailers Association, which represents businesses that sell tobacco products.
"Mark Killian put on two people who are very well-known in tobacco-control areas," says Bruce Samuels, a local attorney who has published studies on tobacco-industry tactics. "And Greene and Fife put on two people each who are questionable in their commitment to tobacco control, at best."
As the governor and Senator Greene were appointing TUPAC members with less than shining antismoking credentials, Dillenberg was reading the fine print of the legislation implementing the tobacco-tax initiative.
That law directs TUPAC to make recommendations to the Department of Health Services "concerning the programs established and funded" by the Legislature.
The past tense was not lost on the director and his underlings. When the committee sat for its first meeting in August, Dillenberg's department informed the committee members that contracts for an education campaign involving the Phoenix Suns and the Arizona Cardinals already were nearing completion.
Apparently, no competing proposals had been solicited, raising questions about whether the contracts would be proper, given the general requirements for competition in state purchasing.
Some of the committee members felt like they'd been run over by a truck.
"When I walked out of the first meeting," says Jack Braddock, "the first guy I ran into was [tobacco lobbyist] Don Isaacson. I told him that, asfar as I was concerned, if it was going to be handled that way, I was going to write the governor, thank him for putting me on the committee, but I wasn't interested in being on a committee that had no input."
Director Dillenberg's spokesperson, Brad Christenson, says that the director and DHS decline to comment on the tobacco tax or TUPAC committee.
On September 29, a 12-page letter from Steven Duffy, an attorney with tobacco lobbyists Ridge & Isaacson, protested the Department of Health Services' rule-making procedures, the legality of the Suns contract and the department's narrow reading of legislation on tobacco-tax revenue.
Five days later, Michelle Ahlmer and Jack Braddock sent a letter to Dillenberg complaining on similar grounds.
Eventually, the dispute was picked up by the press. On October 24, Dillenberg and DHS were roundly criticized for trying to rush through the Suns and Cardinals contracts before the TUPAC committee could review its actions. It was obvious, local pundits declared, that Dillenberg had surprised the committee with news of the Suns contract because he knew that giving money--more than $600,000--to an organization run by Jerry Colangelo would be unpopular, given the debate over a publicly financed baseball stadium being built for Colangelo's Arizona Diamondbacks.
Representative Don Aldridge, Republican of Lake Havasu City, called for Dillenberg's head.
The next day, Dillenberg visited editorial boards at two local dailies. The director defended the Suns contract as exactly the kind of thing Arizonans had voted for, and argued that if there was resistance from tobacco interests, it was only an indication of how much it threatened tobacco sales.
A second wave of editorials appeared, this time questioning the motives of TUPAC members Braddock and Ahlmer.
Braddock says his connection to tobacco interests has been overblown. He doesn't smoke, has never sold tobacco products and guesses that Governor Symington appointed him simply because the governor wanted someone to represent Tucson. He says the flap over the Suns contract was a minor disagreement that has resulted in better communication between Dillenberg and the committee.
"Those contracts were not signed until after we had a meeting and said it was okay by us," he says.
In a letter that went out to the entire state Legislature, Michelle Ahlmer expressed shock that her ties to the tobacco industry would be considered a conflict of interest. "Outside of retailers who sell nothing buttobacco products," she wrote on November 7, "retailers do not depend on tobacco sales of any kind as the lifeblood of their business."
Dr. David Nielsen, the ear surgeon on TUPAC, has another view. "It'spretty obvious that the people who have been selected to serve on the committee are there to represent the interests that put them there. I think that's not a good idea," he says.
Professor Stanton Glantz has traveled extensively, studying tobacco-control programs and tobacco-industry tactics. He calls Arizona's antismoking contract with the Phoenix Suns "one of the smartest, most innovative programs I've seen anywhere in the world. It's got the highest probability of success of anything I've ever seen to reach kids."
What makes it such an effective program for children, Glantz points out, is that it doesn't focus solely on children, but on adults as well.
Children take up smoking, Glantz contends, because they perceive it as an adult activity. And as long as this perception doesn't change, even the most aggressive campaigns against smoking fall flat.
In Glantz's view, an effective marketing campaign will encourage quitting among both children and adults.
"The most effective ads," Glantz says, "contain three messages: The tobacco companies are out to get you, nicotine is addictive, and secondhand smoke kills."
When adults respond to these ads and try quitting, it changes the perception of children and teens, Glantz claims.
Unfortunately, Glantz says, the tobacco industry understands advertising very well. He contends that tobacco-industry spokespeople and legislators friendly to their cause lobby to direct antismoking campaigns solely at children. It sounds like a perfectly legitimate goal: Give money to schools for in-class presentations designed to keep kids from starting to smoke.
Glantz and other health professionals argue that the tobacco industry knows this kids-only approach is less effective than one aimed at the general population.
Dr. John Pierce of the University of California at San Diego agrees. "Curricula in schools, no matter how good they are--the effect is temporary with no long-term effect. We spent $124 million on schools over five years in California and we got no change in smoking among kids. Why? Because, meanwhile, the tobacco companies hit the streets with a marketing campaign and trinkets to counter the school program.
"It's a big mistake to target only children. The big change in California came across the board in adults. And as adults quit more frequently, it comes across to children that quitting is an adult behavior.
"In Sydney," says the Australian native, "we saw a big drop in the first year [of a similar tax initiative]. Second year, a continued drop. Third year, we were told to focus on children, and the effect disappeared."
"The group you can have the most impact on is the 18- to 25-year-olds," says Glantz. "That's not to say you don't want to have a youth component, but it's stupid to focus solely on youth."
Pierce reports that in California, the Proposition 99-funded media campaign which began in 1990 resulted in a 12 percent drop in tobacco-product sales and no increase in teen smoking--even though teen smoking went up in the rest of the country. Both Glantz and Pierce say that results would have been even better if initial, hard-hitting advertisements and slogans hadn't been supplanted by diluted replacements, and if Governor Pete Wilson hadn't diverted millions from health-education accounts. Each diversion has been found illegal by California courts.
Glantz claims that the same sort of tactics are being used against Arizona's program while it's still in its infancy. Already, he says, Arizona's Department of Health Services has bowed to political pressure, rejecting slogans like "Be Tobacco Free" for what he believes is a more vague "Be Smart. Don't Start" motto.
As yet, it is not clear how much effect this purported political pressure has had.
Last week, DHS officials and advisers awarded a $5.5 million antismoking advertising contract to the Riester Corporation, which will design electronic and print ad campaigns as well as programs for schools. The award had the support of Dillenberg and has drawn negative response from at least one legislative opponent of the tobacco tax.
Only the ads themselves will show the overall thrust of the media campaign.
"The Tobacco Institute does not want to see kids smoke," says Steven Duffy, who is sitting in the book-lined conference room of the law firm Ridge & Isaacson on North Central Avenue. The firm is registered as a lobbyist for the cigarette manufacturer's trade association based in Washington, D.C.
"Given that they don't want kids to smoke, that's where the money should be directed. The best way to do that is to give it to the people who know how to teach children, namely schoolteachers," he says.
Duffy's letter to Jack Dillenberg claiming that the Phoenix Suns contract was procured illegally has had a great effect on the Department of Health Services, observers say. Duffy downplays its influence. His firm simply saw an abuse of power, he says, and acted accordingly.
Although DHS responded to most of the charges in his letter, Duffy claims that the department hasn't answered all his points in a satisfactory way, and the firm is considering a lawsuit.
Duffy says his interest in the Suns contract is purely procedural. "I'm not here to tell you that having a contract with the Suns generally is a good idea or a bad idea. I don't have an opinion on that. We raised the issue of the Suns contract only in the sense of the way, the process, in which it came to be. And we never said one word on the substance of the contract."
He acknowledges that his firm has a special interest in what DHS decides to do with the health-education money. "There's no secret we represent the Tobacco Institute," he says. "And, kind of by analogy, the taxpayer, when it comes right down to it."
Duffy adds: "I think tobacco is a legal product. It has been a legal product since before this was a country. I think our representation is legal and correct, and I don't apologize for it at all."
In response, of course, antismoking advocates quote health statistics: 400,000 deaths each year in the United States because of tobacco use. Tobacco is blamed in 21 percent of all heart disease deaths, 87 percent of lung cancer deaths and 30 percent of cancer deaths.
"Tobacco is not like anything else," says Dr. David Nielsen. "It is the No. 1 health problem in the nation."
Bruce Samuels, the Phoenix attorney who has studied tobacco-industry tactics with Dr. Glantz, says that focusing on procedural issues, such as the method for awarding the Suns-Cardinals contracts, is a common way that tobacco lobbyists take attention away from what really concerns them: effective media campaigns.
"Now that the tobacco tax is being collected, [the tobacco industry] could care less about the money going to hospitals and doctors. That, to them, has no impact on tobacco sales. What they're worried about is health-education money," Samuels says.
